Cytomegalovirus can make immune thrombocytopenic purpura refractory

Abstract

SummaryImmune thrombocytopenic purpura (ITP) is characterized by decreased platelet numbers secondary to platelet destruction and reduced platelet production. Even if the ITP persists, it typically responds to 'ITP-specific' therapies, such as intravenous immunoglobulin, steroids, intravenous anti-D, and splenectomy. Several reports, including our previous study, have implicated cytomegalovirus (CMV) in the pathogenesis of infrequent cases of ITP that were not severe in nature. A recent study from China suggested that CMV is the aetiology of some cases of acute ITP of childhood and may require different treatment. We report two adult and two paediatric patients with refractory, severe, symptomatic thrombocytopenia, who were diagnosed with ITP and found to have active CMV infection. Their presentations included fever, transaminitis, neutropenia, and atypical lymphocytosis, but in particular, treatment-refractory, severe ITP. Treatment with steroids appeared to worsen the CMV-ITP. All four cases showed improvement in platelet counts within two weeks of starting ganciclovir and cytogam and tapering steroids. Based on the four patients described here, we believe that, in certain cases, CMV infection will result in symptomatic, severe, refractory ITP, which may be indistinguishable from typical ITP. Eradication of CMV with antiviral therapy improved the ITP in these cases.

Six Cases of Infectious Mononucleosis by Cytomegalovirus as Diagnosed by Multiplex Virus PCR Assay

“…Regarding platelet count, Patient 3 showed marked thrombocytopenia of 2 × 10 9 /L, possibly being immune thrombocytopenic purpura as previously reported [13], which was later resolved with immunosuppressive therapy. The median percentage of atypical lymphocytes was 21.3%, ranging from 19.0 to 36.9%.…”

Mycoplasma pneumonia Infection: A Possible Trigger for Immune Thrombocytopenia

“…Finally, direct binding of Mycoplasma to the platelets, generating a complex that is then recognized as foreign by the immune system, might be another option. Whatever the mechanism would be, a special behavior of a subset of ITP caused by a certain organism is an intriguing option, as was suggested recently for ITP triggered by CMV infection [27].…”

Cytomegalovirus: A possible cause of Persistent Refractory Immune Thrombocytopenic Purpura

“…In a study, a combination of both IV ganciclovir and IV cytogam had been used to optimize rapid suppression of the CMV. 5 The same study showed that use of steroids and other immunosuppressive treatment may exacerbate the primary CMV infection and worsen the ITP, or at least prevent it from improving. Also of interest is that, when CMV is controlled by anti-viral therapies, normal treatments for ITP, such as IVIG and splenectomy regain their effectiveness.…”

“…Also of interest is that, when CMV is controlled by anti-viral therapies, normal treatments for ITP, such as IVIG and splenectomy regain their effectiveness. 5 The response rate of platelet counts following treatment of CMV has seen to vary widely between studies.…”